Do you feel a little dirty?

[Tired]

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Primary Care is easily the most useless field in medicine. Filling out forms, treating minor ailments, and then sending the patients to the serious doctors (ie - specialists) when they're actually sick. Eventually the NPs will take over their jobs entirely, with no discernable impact on society at all . . .

 

[dilated]

You say "those docs are just doing more" but the truth is that even adjusted for relative value units, the people doing procedures are making disproportionately more. Besides, I think its obvious anyway that a derm earning 2-3x the income of a pediatrician is not necessarily doing 2-3x more work.

And what's the RVU for having to come in at 4am on Friday night to evacuate a brain bleed? Dermatologists are a ridiculous basis for comparison because they have substantial cash-only opportunities that most physicians can only dream of (and a far more anticompetitive specialty board than most). Most of the "proceduralists" you are deriding spent far longer in training and work substantially longer hours with worse call than your average family practice doctor.

Are family doctors underpaid? Yes, but what else do you expect when NPs and PAs can independently do everything FPs can in some states -- FPs making 250k a year while NPs make 80k for the same scope of practice? Good luck putting that genie back in the bottle.

 

[OncoCaP]

Primary Care is easily the most useless field in medicine. Filling out forms, treating minor ailments, and then sending the patients to the serious doctors (ie - specialists) when they're actually sick. Eventually the NPs will take over their jobs entirely, with no discernable impact on society at all . . .

I suppose then that FP's should just hire a bunch of NP's and PA's and manage them, right? (I think many already do this as well)

 

[GoBuckeyes913]

Are you familiar with RVUs and conversion factors and how CMS determines reimbursement schedules, and the disproportionate representation of surgeons and other specialists on the RUC committee? I'm not trying to be smart; I'm genuinely wondering. Your idea that those who are doing more work should be paid more goes without saying. That was the whole idea with Relative Value Units- a way to compare CPT code to CPT code and measure the amount of time, skill, effort, etc. required to complete each task. Medicare (and by adoption almost every private health insurer) then has a conversion factor by which they will multiply a code's RVU to determine reimbursement.

For reference, a inpatient hospital management code is worth a little under 3 RVUs as is the 11400 code (benign excision <.5cm). So you would expect that the person removing the mole would earn approximately the same reimbursement as the person doing the E/M hospital visit. That's where the adjustment you're referring to (for doing the additional work for the procedure) should come into play. But in reality, the conversion factors applied to the E/M codes are on average 30% lower than the conversion given to procedural codes, which makes this a double whammy. That 3-RVU hospital visit gets paid $101 by Medicare but the dermatologists 3-RVU mole removal earns $210. If they also did the E/M for that visit (although its more likely that a PCP did and then referred) they can also charge seperately for that (which is why they are in the habit of making people schedule two consultations- one to look at the mole and then another to remove it).


It has been determined that on average a primary care physician gets reimbursed about $58.00 per relative value unit of work across all codes, while a procedure is reimbursed about $76.00 per unit. There's no rational basis for doing this! A procedure that takes four times the "work" is going to be paid six times the money. Therein lies the disparity, because the bulk of codes for a primary care physician are going to be E/M and not procedures, so they are not being fairly compensated for, literally, the relative value of work that they are putting in. Which, of course, makes procedures more financially lucrative and potentially overused.

You say "those docs are just doing more" but the truth is that even adjusted for relative value units, the people doing procedures are making disproportionately more. Besides, I think its obvious anyway that a derm earning 2-3x the income of a pediatrician is not necessarily doing 2-3x more work.

Edit- here, this explains the problem very clearly:
http://www.aafp.org/fpm/20070400/13arey.html

I am very familiar with RVUs/reimbursement, coding, etc. There are no doubt flaws within the system as I stated in the post you replied to (FPs getting paid less to remove a skin tag vs. Dermatologists). A procedure should be reimbursed the same amount of money no matter what type of physician is performing it. In retrospect, Derm is a bad example in this matter, mainly due to their cash-only business.

FP's are underpaid, however a recent post does make a good point about NP/PA's doing the exact same job for a lot less money. This is a whole separate issue though. However, in general FPs are more known for E/M than performing procedures (excluding rural areas). So whether or not their E/M code falls into the same category for a minor procedure code does not entitle them to the same reimbursement since, essentially, they ARE doing less by not doing a procedure in addition to E/M. Hopefully the "system" realizes these things and can adjust accordingly someday.

 

[LizUMD]

And what's the RVU for having to come in at 4am on Friday night to evacuate a brain bleed? Dermatologists are a ridiculous basis for comparison because they have substantial cash-only opportunities that most physicians can only dream of (and a far more anticompetitive specialty board than most). Most of the "proceduralists" you are deriding spent far longer in training and work substantially longer hours with worse call than your average family practice doctor.
Are family doctors underpaid? Yes, but what else do you expect when NPs and PAs can independently do everything FPs can in some states -- FPs making 250k a year while NPs make 80k for the same scope of practice? Good luck putting that genie back in the bottle.

Whoa, fact check. I never "derided" any specialists! Please read for comprehension. My point is that the PCPs should be paid more, not that specialists should be paid less. Which you seem to be in agreement with. But to answer your question- I'm sure the RVU for the 4am call you described will be roughly equivalent to the RVU of an ob/gyn or rural family practitioner coming in for a 4am delivery, but it will get paid a hell of a lot more. And, FYI, we are discussing dermatologists because that was a specialty named by the OP. The discussion at hand is why most high achieving med students eschew primary care in favor of the "lifestyle" specialties which afford better hours and better pay. You're throwing something totally unrelated into the discussion by bringing up the more grueling specialties. And another FYI- two of the three very desirable specialties that the OP mentioned (dermatology and ophthalmology) do not require "far longer in training" than FP but rather a difference of exactly one year and in fact are shorter than ob/gyn training.

As for the NPs, don't kid yourself into thinking they are only interested in taking over primary care. What do you think the real purpose of the new DNP degree is? To further convince the state boards (and Medicare) that as doctorally prepared healthcare providers they are in fact a physician equivalent. There's already talk in the ivory tower at Columbia of organizing a push to petition the federal government for a cut of the money to establish DNP residency programs. Do you really think they won't come after the lucrative specialties once they get that foothold? Talk about letting a genie out. All physicians should be concerned about a midlevel takeover of primary care.

 

[SocialistMD]

Whoa, fact check.
And another FYI- two of the three very desirable specialties that the OP mentioned (dermatology and ophthamology) do not require "far longer in training" than FP but rather a difference of exactly one year and in fact are shorter than ob/gyn training.

While you were fact checking, you should have seen that ob/gyn, ophthamology and dermatology are actually the same length (4 years).

 

[GoBuckeyes913]

Wait, are you saying "personal interests" are not influenced by lifestyle consideration of which pay is a significant part? Do you seriously think if derm pay was cut in half and the hours per week increased they would still be attracting as many students?

Also, whats with all the "#1 in my class went into primary care" examples? You think people would be a little more statistical in their reasoning. It's not an issue of whether high performers go into primary care or subspecialize its a question of whether high performers are disproportionally represented in specialties like derm and if that is a beneficial outcome in a broad sense.

Nope. Sometimes "personal interests" are influenced by lifestyle of a profession. What person wouldn't want the cush lifestyle of a dermatologist? In general though, people are usually going to pursue what they enjoy doing over lifestyle alone. Usually. Oh, and my apologizes for not providing statistical numbers for you 🙄 I was merely siting an example in support of my comment.

 

[GoBuckeyes913]

The discussion at hand is why most high achieving med students eschew primary care in favor of the "lifestyle" specialties which afford better hours and better pay. quote]


I don't know if most high achievers purposely eschew primary care for specialties. As I stated in another comment, generally people are going to pursue what interests them over lifestyle alone.

 

[LizUMD]

While you were fact checking, you should have seen that ob/gyn, ophthamology and dermatology are actually the same length (4 years).

LOL- wrong. Derm and optho are both three-year residencies (plus one year internship = 4 years). Ob/gyn is a four-year residency (plus one year internship = 5 years).

You might also want to learn how to spell ophthalmology if you're going to pretend to correct me.

 

[LizUMD]

The discussion at hand is why most high achieving med students eschew primary care in favor of the "lifestyle" specialties which afford better hours and better pay. quote]


I don't know if most high achievers purposely eschew primary care for specialties. As I stated in another comment, generally people are going to pursue what interests them over lifestyle alone.

Without actual statistics this would be hard to discuss. Maybe you're right. I think many others (myself included) would suspect that pay and lifestyle concerns play at least an equal part in that decision. This is probably especially true for women.

 

[Drogba]

Nope. Sometimes "personal interests" are influenced by lifestyle of a profession. What person wouldn't want the cush lifestyle of a dermatologist? In general though, people are usually going to pursue what they enjoy doing over lifestyle alone. Usually. Oh, and my apologizes for not providing statistical numbers for you 🙄 I was merely siting an example in support of my comment.

I didn't ask for statistical data I only suggested that peoples' analysis be more in terms of group decision making instead of "this kid I know" type arguments. Of course high achievers will go into primary care, there are some high achievers going into every field of medicine. But on a population level it is obvious that high achievers are attracted to the lifestyle specialties. The attempt to separate lifestyle from "what people enjoy doing" is not any easy thing to accomplish.

 

[smq123]

While you were fact checking, you should have seen that ob/gyn, ophthamology and dermatology are actually the same length (4 years).

LOL- wrong. Derm and optho are both three-year residencies (plus one year internship = 4 years). Ob/gyn is a four-year residency (plus one year internship = 5 years).

You might also want to learn how to spell ophthalmology if you're going to pretend to correct me.

Actually, OB/gyn is a four year residency. Including internship. So it's 4 years total. Just like derm and opHtho. (Oh, unless you're a DO. Then you might have to do that prelim year that DOs need to do in some states.)

And it's kind of mean to correct someone else's spelling of "ophthalmology" when you yourself misspell its abbreviation.

 

[LizUMD]

Actually, OB/gyn is a four year residency. Including internship. So it's 4 years total. Just like derm and opHtho. (Oh, unless you're a DO. Then you might have to do that prelim year that DOs need to do in some states.)

And it's kind of mean to correct someone else's spelling of "ophthalmology" when you yourself misspell its abbreviation.

Okay, I'll own up. I've been served. Of course ACGME programs are 4 PGY total. Mom and and big brother are both DOs and yes, there you need the rotating osteopathic internship first. Well, if you want osteopathic board approval. Hence the "+1 internship" bit. So really, I humbly apologize.

Don't know why I was nasty in my reply. It was uncalled for, and worse, I was wrong on both counts. This place seems to breed negativity in me, you see it with everyone I guess, and I don't know why. I think I'd best step away for awhile and lay off the debate, lest I go around insulting more people and making a bigger *** of myself. I still believe strongly in my overall point, but its time to take my ball and go home for a nap.

Thank you for the correction and for doing it in a classier manner than I did. I will try to learn a lesson.

 

[PeepshowJohnny]

The thing is, I can't feel dirty if I'm a dermatologist or an ophtho, because the people I see who chasing money the most when they're out in practice are the FP's and the IM general docs. Honestly, they're the only people I've seen talk about reimbursements and pay with students.

Sometimes this is sensible stuff, for example, setting aside a day to do minor in office procedures, but I've seen some somewhat "shady" things done by PCPs that make it clear the motivation is really only increasing their bottom line and NOT on helping patients.

Really, the only people I've see exempt from this are the pediatricians, which is why they get y respect. I don't know if they were just saints in the office I rotated in, they would probably keep working if they were only paid 40k a year because they love it so much.

 

[Pinkertinkle]

Ophthos don't have it nearly as easy as derm. Please spare them.

 

[Slide]

I don't know why people lump ophtho into this group that the OP is talking about; they're pretty damn important in society (important enough to already be a medical specialty centuries ago) and have to undergo a lot of training to do both clinical and surgical work. It's not hardcore as doing a whipple in gen surgery, but cataract surgery and cornea transplants still require tons of training for successful results.

I have to seriously disagree with anyone that says ophthalmologists are not as useful as other fields of medicine; I mean, it would be difficult to imagine a society where a significant proportion of society is blind or is severely visually-impaired without any remedy.

 

[def jeff]

To answer the OP's question, I think we should all feel dirty unless we are consciously dedicating each day's work to the motherland.

 

[peanutbutterman]

What about the idea that those that want to go into competitive supspecialties try harder in their classes in order to get honors and high board scores. I myself want to subspecialize...not for the lifestyle...but because it is what interests me. I know that if I was going into primary care, I wouldn't try nearly as hard to memorize all the asinine little details that we won't ever have to know in real life.


In other words, maybe those that know they want to go into primary care don't worry about being #1 in the class. And maybe those that know they want to subspecialize do worry about it.

 

[SocialistMD]

LOL- wrong. Derm and optho are both three-year residencies (plus one year internship = 4 years). Ob/gyn is a four-year residency (plus one year internship = 5 years).

You might also want to learn how to spell ophthalmology if you're going to pretend to correct me.

God forbid I make a typeo 🙄. I'm sure I could search previous posts I've made where I spelled it correctly. In most circles, having correct knowledge is more valuable than correct spelling, but I forget where I am sometimes...

 

[VoiceofReason]

The right questions have been posed in this thread (Drogba and some others maybe I don't feel like going back), but I doubt we will ever see them addressed.

I wonder what the residency distributions and statistics would look like if all specialties had the same lifestyle-flexibility and equal-proportional reimbursements.

 

[SocialistMD]

I wonder what the residency distributions and statistics would look like if all specialties had the same lifestyle-flexibility and equal-proportional reimbursements.

It is an impossible hypothetical question to answer. By the very nature of the different specialties, some are going to deal with more emergencies, which means some are going to have to come in at odd hours more than others. That said, I know that the people in my class who didn't know what they wanted to do either ended up in pathology, internal medicine, pediatrics or family practice. Medicine and FP were where those who didn't match into the more competitive non-surgical spots also ended up, and general surgery is where the people who applied to the more competitive surgical specialties found themselves if they didn't match. I guess you could say there would be fewer internists, family practitioners and general surgeons, but I don't know that that would be true.

 

[novastorm]

I don't know if I want to belittle anyones specialty but I know plenty of nearly perfect grades/usmle's that go with the less competitive specialties...some people actually care just about the medicine and the rest is secondary...

 

[GoBuckeyes913]

What about the idea that those that want to go into competitive supspecialties try harder in their classes in order to get honors and high board scores. I myself want to subspecialize...not for the lifestyle...but because it is what interests me. I know that if I was going into primary care, I wouldn't try nearly as hard to memorize all the asinine little details that we won't ever have to know in real life.


In other words, maybe those that know they want to go into primary care don't worry about being #1 in the class. And maybe those that know they want to subspecialize do worry about it.

They dont' have to "worry", per se, because primary care has more residency spots and is thus considered less competitive. You are putting in the extra effort because there are a lot less residency spots available, making it more competitive.

The right questions have been posed in this thread (Drogba and some others maybe I don't feel like going back), but I doubt we will ever see them addressed.

I wonder what the residency distributions and statistics would look like if all specialties had the same lifestyle-flexibility and equal-proportional reimbursements.

I think that lifestyle will factor less in the decision than it does today.

 

[MattD]

There is no abstraction in this context. That simply refers to a population of individuals in this case.

The pertinent question to me is not whether someone is "morally corrupt" for going into a specialty for lifestyle reasons or "pursuing their own happiness" but whether the incentive structure that currently exists in medicine produces a good balance of physicians in different specialties for society as a whole. I think its also interesting to examine why certain specialties are so lucrative and what that says about the valuation of services in the medical field and also the success of the medical industry at manipulating the market.

Eh, semantics. I meant what you mean.


As far as the system goes, it's set up to provide a good balance, by limiting the specialist training spots and providing ample primary care spots. Yes, this throttled supply inflates the market value of those specialist skills so that they can demand better hours, higher pay, etc; and it creates competition to get those spots amongst the highest performers in medical school. However, medical schools select for students who will be competent to perform in primary care fields, the licensing exams ensure no one is promoted or licensed without being competent, and licensing boards require CME to ensure continued competence. That's all you can ask for, whether you're talking primary care or a super specialized procedural field. Competence. Because any measurement of expertise beyond that is going to be a subjective matter.

 

[DOCTORSAIB]

Actually, OB/gyn is a four year residency. Including internship. So it's 4 years total. Just like derm and opHtho. (Oh, unless you're a DO. Then you might have to do that prelim year that DOs need to do in some states.)

And it's kind of mean to correct someone else's spelling of "ophthalmology" when you yourself misspell its abbreviation.

Not to derail this endless (and pointless) thread, but a DO doing a MD ophthalmology residency would NOT do a DO internship (AOA accredited) b/c the American Board of Ophthalmology does not accept AOA-only accredited internships. Hence, ophtho residency is still FOUR years for a DO (1 yr of internship + 3 years of residnecy, both ACGME accredited).

If you a DO chooses to do a DO ophtho residency, it's still 4 years with the same 1 + 3 breakdown, except both are AOA-accredited.

Carry on people...

 

[Shredder]

I feel dirty for the entire day any time I come within 5 feet of a patient. Or God forbid actually having to touch them.

 

[beefballs]

I feel dirty for the entire day any time I come within 5 feet of a patient. Or God forbid actually having to touch them.

Amen brother, Amen

I will be in the path lab like some kind of monster in a cave

 

[mm3781]

As an aside, I had squamous cell carcinoma on my back last year. It was biopsied by a family doctor (my mom) and excised by a general surgeon. I don't think the presence of a dermatologist would be absolutely essential in a community to detect and treat most cases. Desirable yes, but essential probably not.
[/quote][/quote]

I'd say it's pretty darned essential if your community has anyone with psoriasis, eczema, pemphigus, BP, epidermolysis bullosa, or any of hundreds of other skin conditions. I think you do the patient a huge disservice by having anyone other than a dermatologist treat these conditions. Sure, a family doc can do the occasional biopsy, send it off for pathology, and then enlist a general surgeon to remove the SCC, or you can have a dermatologist do every part of this (including the pathology) as well as follow-up with the patient long-term. Not to mention, a large number of drugs prescribed by dermatologists are pretty heavy duty (biologics, MTX, cyclosporine, DNCB, the list goes on) and require a certain level of monitoring and follow-up that is not possible unless skin is the only thing you deal with. I don't think it is within the scope of any other physician to do 90% of what dermatologists do (with the exception of perhaps a rheumatologist for certain conditions as they use a lot of the same pharmaceutical agents). Likewise, most dermatologists I know are very well-educated in using a lot of drugs that most other docs wouldn't touch with a ten foot pole (I can't remember the last time I saw a FP using steroids, MTX, and remicaid to treat severe erythrodermic psoriasis). My point is that although FP and IM docs may treat more people on the whole and contribute to the overall health of society in a larger % than dermatologists, in the end dermatologists are most certainly essential for the proper management of most skin conditions. And I'm not saying that FP docs aren't intelligent enough to do dermatology, they just don't have the proper training required to properly manage all skin conditions in comparison to someone who deals exclusively with the skin.

 

[HeadMed]

Naw, not useful until you need a knee replacement, a burn graft, or facial reconstruction after that car accident.....

Come on.

First I am going to be a d&*k.

I don't think I want an ophthalmologist, plastic surgeon, or dermatologist doing my knee replacement.😀 (yes I realize you probably misread ophtho for ortho).

As to the OP, I could make an argument that there are many more less useful fields than these. Take neurosurgeons. What is the usual prognosis of their patients? How much of "society" actually go to these surgeons? Sure they are superstars amongst the medical field, but couldn't society benefit more by these guys choosing a different specialty. Ask around and see how many of your friends have benefited from a neurosurgeon. Then compare that to a derm/plastics/ophtho.

 

[lilnoelle]

Primary Care is easily the most useless field in medicine. Filling out forms, treating minor ailments, and then sending the patients to the serious doctors (ie - specialists) when they're actually sick. Eventually the NPs will take over their jobs entirely, with no discernable impact on society at all . . .

Unless you work in a rural area in which case the primary care physicians do it all. I don't think I'd ever do family practice in an urban community, but being a rural family practitioner does sort of appeal to me. In a rural community, I think a family practitioner (or a surgeon) really can do the most good. A specialist wouldn't positively affect the communities health as much as a general doc would

 

[la petite mort]

My cataracts were so bad that at three years old (before extensive laser surgery), I was legally blind. Before this thread, it hadn't even occurred to me that someone might perceive ophtalmology as being a dispensable specialty. 😕

I kind of know what you meant, though, with the post. And yeah, I've been there before too: but think pragmatically. Every single classmate of yours that devotes their life to (yeah, yeah, some of them do the occasional reconstruction after a car accident or altruistic work in third-world countries) tit jobs, face lifts and microdermabrasions after school is one less you'll have to compete with in the specialty you want, whatever that may be.

 

[la petite mort]

Unless you work in a rural area in which case the primary care physicians do it all. I don't think I'd ever do family practice in an urban community, but being a rural family practitioner does sort of appeal to me. In a rural community, I think a family practitioner (or a surgeon) really can do the most good. A specialist wouldn't positively affect the communities health as much as a general doc would

Me too.